Prescription Skin Lightening Agents: Part 1

In this two-part series we continue to cover various prescribed methods for evening out skin tones. Part 1 looked at hydroquinone and mequinol. Part 2 covers azelaic acid, corticosteroids, and more.

In my practice, one of the most common concerns among people of color is uneven skin tone due to hyperpigmentation, or irregular darkening of the skin. Over the past few months, I’ve written a number of posts about hyperpigmentation concerns – including irregular patches, spots and scars – and which conditions warrant a consultation with a dermatologist.

Hyperpigmentation can appear in all skin types. Most cases are purely cosmetic, arising from a number of causes including acne, wounds and scarring, eczema, sun damage, and dry skin in general. The condition is more bothersome for those with darker skin tones because it can be so visible.

Fortunately, there are a number of good therapies to consider. Laser treatments are an excellent option for treating hyperpigmentation in darker skin tones. However, it is essential that you undergo treatment with a doctor who has extensive experience in treating olive and darker skin tones with laser. An inexperienced provider may very well make the condition worse! And while laser treatment is a great therapy, you may choose to start with more convenient at home products and therapies first.

There are many effective skin lightening products and methods, including prescription and over-the-counter treatments that can provide good results. In general, these topical preparations work in one of three ways: destroying the cells in the skin that create melanin (melanocytes); blocking essential steps in the process by which melanocytes produce new melanin (melanin synthesis); or exfoliating the outermost layer of the skin (stratum cornea) to remove excess melanin and allow lightening products to penetrate into the skin more efficiently.

If you are seeking treatment for highly visible or resistant hyperpigmentation, ask your dermatologist about these prescription treatments:
Hydroquinone: Handle with care
Hydroquinone is considered the “gold standard” when it comes to effectiveness. However, some dermatologists consider it a somewhat controversial medication because it can cause skin damage at high concentrations. In fact, hydroquinone has been banned in some countries because of fears of a cancer risk. It works by blocking a critical step in the synthesis of melanin.

When hydroquinone was first introduced (at 2% strength), there was good science and data behind its safety as well as its effectiveness in inhibiting melanin production. What concerns me most is that newer and stronger forms have flooded the market with much less scientific analysis. Hydroquinone is now available in concentrations up to 12%; note that all products containing 3% and greater are to be prescribed by a physician.

I cannot stress enough that there is a real danger in self-medicating with hydroquinone at higher concentrations without professional guidance on proper use, risks, and side effects. There are a lot of new choices when it comes to hydroquinone products. Various brands now offer hydroquinone combined with other ingredients that are thought to increase its potency such as tretinoin, glycolic acid, vitamin C, and steroids. But what is the best formulation? Is there any increased risk of cancer in patients who use hydroquinone? How long is it safe to use hydroquinone? There are many unanswered questions.

What do we know for sure? To start, hydroquinone will bleach skin without discrimination, so it should not be used on the full face. It should only be used as a “spot treatment,” under a dermatologist’s supervision. Care and discipline must be practiced to get the desired result. If it is used beyond the borders of affected areas, it may cause lightening of a larger area than intended (“halo effect”). Halos are not easily reversed even with the hydroquinone is discontinued. Lastly, over-the-counter as well as prescription strength hydroquinone should be avoided during pregnancy and while breast-feeding.

Mequinol: Excellent for sunspots
Mequinol is available in the U.S. in a 2% concentration, usually combined with tretinoin, and is harder to get without a prescription. Mequinol does not damage the melanocyte like hydroquinone, and it can be an excellent treatment for sunspots and other causes of hyperpigmentation.

However, I urge caution to those with darker skin tones because mequinol can actually cause post-inflammatory hyperpigmentation for unknown reasons. It can also cause irritation in all who use it and must not be used during pregnancy or breast-feeding.

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